114 www.pediatriadanas.

com
Objective - To fnd out whether involvement in bullying beha-
viour precedes psychosomatic symptoms or whether these symp-
toms precede involvement in bullying behaviour.
Subjects and methods - A six-month longitudinal study with base-
line measurements taken in the autumn of 2008 and follow-up me-
asurements in the spring of 2009 in four elementary schools in the
Siroki Brijeg municipalities. The study included 536 children aged 11
to 15 years, who participated by flling out a questionnaire on both
occasions of data collection. A self-administered questionnaire mea-
sured peer violence and a wide variety of psychosomatic symptoms.
Results - Children involved in bullying behaviour at the beginning
of the school year compared to children who were not involved
in bullying behaviour had signifcantly higher chances of deve-
loping psychosomatic symptoms such as nervousness and ten-
sion (OR=2.59; p=0.010), feeling tired for no reason (OR=2.0;
p=0.008) and a feeling of energy loss (OR=2.18; p=0.050) during
the school year. At the same time, some psychosomatic problems
increase the likelihood of involvement in bullying behaviour. Chil-
dren who were identifed at the beginning of the school year as
neutral and who had psychosomatic symptoms which had ma-
nifested as dizziness (OR=0.97, p=0.019), feeling tired for no
reason (OR=1.84, p=0.018), pain (OR=2.45, p=0.001), eye pro-
blems (OR=1.94, p=0.047) and a feeling of energy loss (OR=2.06,
p=0.045) were at greater risk of participation in peer violence du-
ring the school year.
Conclusion - Many psychosomatic health problems follow invol-
vement in bullying behaviour. Furthermore, our results indicate
that children with some psychosomatic health symptoms are at
increased risk of being involved in bullying behaviour.
Key words: Bullying Longitudinal study Psychosomatic diff-
culties
Original article
Damir SESAR,

Kristina SESAR
2
PSYCHOSOMATIC PROBLEMS AS THE RESULTS OF
PARTICIPATION IN BULLYING BEHAVIOUR OR RISK FACTOR
FOR INVOLVEMENT IN BULLYING BEHAVIOR
Pediatric Primary Care
Health Centre iroki Brieg
Bosnia and Herzegovina
2
Centre for Mental Health
Health Centre iroki Brieg
iroki Brieg
Bosnia and Herzegovina
Kristina Sesar
Centre for Mental Health
Health Center iroki Brieg
88220 iroki Brieg
Bosnia and Herzegovina
kristina.sesar@tel.net.ba
Tel.: + 387 39 703 870
Fax.: + 387 39 704 936
Received: February 19, 2012
Accepted: May 31, 2012
Copyright 2012 by
University Clinical Center Tuzla.
E-mail for permission to publish:
paediatricstoday@ukctuzla.ba
Paediatrics Today 2012;8(2):114-126
DOI 10.5457/p2005-114.46
115
abuser and the child being abused (6, 7, 8).
It can be manifested in the form of verbal
abuse, physical aggression or relational abu-
se. The frst two forms of violent behaviour
are sometimes called "direct" peer violence,
because they include direct aggressive beha-
viour. Relational violent behaviour is seen
in manipulation of relationships in the peer
group in order to exclude somebody from
that peer group (9).
The frequency of bullying behaviour va-
ries in relation to how bullying behaviour is
defned, as well as in relation to the country
in which the research is being conducted in
a range from 9% to 54% (10, 11-13). When
we take into account the frequency of vio-
lent behavior in regard to the role in violent
behavior, the research results show that there
are 7 23% of children included in violent
behaviour categorized as bullies, 5 12% of
children are categorized as victims and 2
21% as bully/victims (12, 14-17). According
to the research results of Nansel et al. (10)
conducted in 25 countries, the smallest num-
ber of bullies (3%) is in Sweden and Wales,
whereas the largest number of such children
is in Denmark (20%). Lithuania has the lar-
gest number of bully/victims (20%), where-
as Sweden has the lowest (1%).
Research into bullying behavior in Bo-
snia and Herzegovina (BH) is still at its be-
ginning. The results of one such study whose
goal was to defne the frequency of bullying
behavior in the senior grades of elementary
school showed that 57% of children partici-
pating in the total sample were identifed as
participants in bullying behavior, 13% were
identifed as bullies, 16% were identifed
as victims, whereas 28% were identifed as
bully/victims (18).
Cerni Obrdalj et al. (19) conducted rese-
arch to identify the forms of violent beha-
viour among elementary school children in
two cities in Bosnia and Herzegovina. The
research included 484 students (4th - 8th gra-
Introduction
Research into peer violence was started in
the Scandinavian countries under the term
"mobbing", introduced by the school doc-
tor, Heinemann. Heinemanns (1) study was
the frst research into peer violence among
elementary school children. His observa-
tions made teachers, as well as researchers
start thinking about acceptance of such
behaviour (2). This was followed by resear-
ch by Dana Olweus (3), who systematically
studied the nature, frequency and long-term
consequences of peer violence (mobbing)
in Scandinavian schools. In the early 90th,
the research was started in Great Britain by
using Olewuss instrument for studying vi-
olence among children (2). However, in the
research the volume of behaviour related to
child violence was extended. The validation
also included behaviour such as: spreading
rumors, social isolation, destruction, as well
as loss or stealing of personal property. Due
to the changes in the defnition of violent be-
haviour, the term mobbing was substituted
by the term bullying (4, 5).
In our language the term bullying is used
to replace the following terms: child violen-
ce, child abuse, victimization, problems of
the bully/victims, peer violence and scho-
ol violence. Despite the fact that the term
"child violence" is the most commonly used,
Olewus (3) distinguishes the terms violence
and bullying. He defnes violence as aggre-
ssive behaviour, where the abuser uses his
body or some other object in order to inju-
re somebody (relatively seriously), or to hurt
somebody. Therefore, Olewus states that the
terms violence and bullying can be used as
synonyms only if negative actions include
physical force.
Generally speaking, bullying behaviour is
defned as behaviour whose goal is to hurt or
harm somebody. It is characterized by repe-
tition, as well as the difference between the
physical and psychological force between the
D. Sesar and K. Sesar Bullying behavior and psychosomatic symptoms
116
pathological symptoms (25), as well as some
symptoms usually related to serious psychotic
disorders.
In the third phase, the author suggests
that what follows after a momentary and
temporary stressful reaction depends on the
intervention of situational and psychological
factors defning the context in which the re-
actions happen, and which may increase or
reduce their intensity.
The factors which usually reduce stressful
reactions include phenomena such as: a wide
spectrum of effective strategies for dealing
with stress, the help and support of friends
and family, a strong feeling of controlling
stressors, optimism and a point of view that
stressors are a challenge. The factors increa-
sing the effects of stressors include: lack of
social support, inappropriate strategies of
dealing with problems, pessimism, a feeling
of uselessness and a feeling that the stressors
are a terrible threat. In the fourth phase, the
interaction between particular stressors, par-
ticular people and particular circumstances
causes physical and/or psychological pro-
blems which may be mild and temporary
(weak anxiety, headache or a few sleepless
nights) or serious and permanent (anxious
disorder, temper disorder or physical illness).
An increased level of excitement as a
reaction to a stressful event, as well as the
correlation between the increased level of
excitement and psychological and health
diffculties, are not only found in children
exposed to violent behaviour, but also in
children involved in violent behaviour, as
bullies , i.e. bully/victims (26, 27).
In research conducted among senior-gra-
de elementary school students in Australia,
a list of symptoms of health problems was
presented to the examinees. The boys and
girls who reported being exposed to violent
behaviour at least once a week in the pre-
vious year had higher results on this scale in
comparison with other children. The most
de of elementary school) in Stolac and Po-
susje. It was found that the most common
form of violence in school was verbal abuse
(59%), whereas the least common form of
violence was sexual abuse (2.2%). The boys
were more commonly involved in physical
violence, whereas the girls were more invol-
ved in verbal violence.
Some recent research results indicate that
there is a correlation between participation in
bullying behavior and psychosomatic diffcul-
ties (16, 20-23). Psychosomatic diffculties are
defned as clinical symptoms which do not
have organic pathology. The most common
psychosomatic symptoms manifested in the
pre-school and school age, as well as in the
adolescence include: abdominal pains, hea-
daches, chest pains, fatigue, back pains, leg
pains, concerns for health and breathing pro-
blems. These commonly seen symptoms sho-
uld be distinguished from somatic or neurotic
disorders which are more commonly seen in
adults. The frequency of psychosomatic diff-
culties in children and adolescents is around
10% - 25%. Psychosomatic symptoms are the
most common response to stress.
In her theory of life changes, Dohrenwend
(24) explained how stressors and stressful reac-
tions contribute to the development of physi-
cal and/or psychological disorders. According
to this author, the frst phase includes stressful
life events varying depending on how far they
are defned by the environment, or in relati-
on to the psychological characteristics of the
central person in the event. The next step in
the model is based on the difference between
the stimulus or the event, indicating the stre-
ssful reaction and reactions to that stimulus
or event. Physiological reactions to stressful
stimulus can be various physical, psycholo-
gical and behavioural responses (palpitations,
anger, impulsiveness), i.e. an increased level of
excitement. Psychological responses to stre-
ssful events can have various forms, including
changes of behaviour and a wide spectrum of
Paediatrics Today 2012;8(2):114-126
117
alth problems did not precede victimization.
However, this research did not include a
wide spectrum of psychosomatic diffculties
such as: headaches, abdominal pain, sleeping
problems, skin problems, emotional tension,
nausea, fatigue, and problems with appetite.
Finding out if involvement in bullying be-
havior precede these symptoms or if these
symptoms occur before participation in peer
violence may help prevent peer violence, as
well as to prevent these psychosomatic diff-
culties. Every day, many paediatricians and
other health workers see children who have
been involved in peer violence or who display
psychosomatic symptoms. Therefore, it is im-
portant to know which symptoms increase the
risk of children participating in bullying beha-
vior, i.e. it is important to know if involvement
in bullying behavior increases the risk of de-
veloping particular psychosomatic symptoms.
The aims of this prospective resear-
ch were to examine: (1) if involvement in
bullying behavior at the beginning of a
school year increases the risk of developing
psychosomatic diffculties during the school
year; (2) if psychosomatic diffculties at the
beginning of the school year increase the risk
that a child will be involved in bullying beha-
vior during the school year.
Material and methods
The research was conducted among 6th
and 8th grade students of all the elemen-
tary schools in the municipality of Siroki
Brijeg. The participants were students at the
First Elementary School in Siroki Brijeg (203
students), the Second Elementary School in
Siroki Brijeg (132 students), the Kocerin Ele-
mentary School (64 students) and the Biogra-
ci Elementary School (79 students). Two ele-
mentary schools are located in the town area,
whereas the other two schools are located in
the rural area of the municipality. The frst
survey was conducted in November 2008,
important difference between the children
exposed to violent behaviour and the others
was seen in headaches, infammation of the
throat and chest pains.
However, it was found that bully/victims,
had more psychosomatic diffculties in com-
parison with victims (28). Fekkes et al. (29)
also found an increased risk of development
of health problems in children involved in
bullying behavior. Children being exposed
to violent behaviour had an increased risk of
developing psychosomatic diffculties such as:
headaches, problems with sleeping, abdominal
pains, problems with appetite and nocturnal
enuresis. It was found that children who were
violent towards other children had an increa-
sed risk of headaches and nocturnal enuresis.
Bully/victims had an increased risk of
abdominal pains, problems with appetite,
nocturnal enuresis and fatigue. The risk of
development of health problems was greatly
increased in comparison with children for
children involved in bullying behavior.
The research mentioned previously inclu-
ded data from other research indicating a
correlation between involvement in peer vio-
lence and psychosomatic diffculties. Howe-
ver, the problem is whether psychosomatic
symptoms occur before involvement in
bullying behavior, or participation in involve-
ment in bullying behavior precede psychoso-
matic symptoms. There has not been much
research dealing with a prospective exami-
nation of the infuence of involvement in
bullying behavior on childrens health. In one
piece of prospective research, according to
our fndings, dealing with an examination of
the cause-and-effect relationships of peer
group violence and health problems, Fekkes
et al. (30) found that the children involved in
bullying behavior had a greater risk of de-
veloping new psychosomatic diffculties in
comparison with children who are not invol-
ved in violence in any way. At the same time,
according to the results of their research, he-
D. Sesar and K. Sesar Bullying behavior and psychosomatic symptoms
118
(to make you upset)?, Have other pupils said
they wouldn't be friends with you anymore,
or said they would tell-tale (tell other people
things about you)?, Have other pupils told lies,
said nasty things, or told stories about you that
were not true?, Have other pupils spoilt activi-
ties (for example, sports games or class activi-
ties) on purpose (to make you upset)?
In the second part of the questionnaire,
personal aggressive behaviour was evaluated
(Have you ever taken others personal belon-
gings?, Have you threatened/blackmailed so-
meone?, Have you hit or beaten someone
up?, Have you done any other things?) as well
as verbal/relational aggression directed to
other students (Have you called other pupils
nasty names? Have you not hung around with
another pupil/other pupils (to make them
upset)? Have you told other pupils that you
did not want to be friends with them anymo-
re, or said that you would tell-tale (tell other
people things about them)? Have you told
lies, said nasty things, or told stories about
other pupils that were not true? Have you
spoilt activities for other pupils (for example,
sports games or class activities) on purpose
(to make them upset)?.
The responses were evaluated on a scale
of 1 to 3, depending on how the examinee
had been included in a violent situation (not
at all/rarely=1, often=2, very often=3)
in the previous three months. The responses
2 or 3 (often and very often) in the part of the
questionnaire in which the examinees were
asked about which behaviour they experien-
ced were categorized as exposure to violent
behaviour or victims. The responses 2 or 3
(often and very often) in the part of the que-
stionnaire in which the examinees were asked
about their behaviour towards other children
were categorized as violent behaviour direc-
ted at other children or bullies.
The responses 2 or 3 (often and very often)
in the part of the questionnaire in which the
examinees were asked about which behaviour
and it was repeated in May 2009. In the frst
round of research 536 examinees were inclu-
ded. The frst sample included results of 478
examinees 232 females (48.5%) and 246
males (51.5%). The second sample included
535 examinees 253 females (47.7%) and
282 males (52.3%). The processing included
only those examinees whose questionnaires
were appropriately completed in the frst ro-
und of the research, that is 478 examinees.
The examinees were from 10 to 14 years old
(12.301.64 years).
Participation in bullying behavior was
estimated using the School Relationship
Questionnaire - SRQ, which was modifed
for self-evaluation of peer violence. The mo-
difcation included a reduction in the number
of questions, as well as the more appropria-
te formulation of questions for adolescents
(31, 32). Standardized questions were used in
the questionnaire, and these were questions
about students relationships with other stu-
dents. The use of the questionnaire in this
research was approved by the authors of the
questionnaire.
For the needs of this research, the questi-
onnaire was translated into Croatian according
to recommended standards for translation of
psychological instruments. The questionnaire
was translated from English into Croatian,
and afterwards a reverse translation from Cro-
atian into English was undertaken. The rever-
se translation showed minor omissions, so the
necessary corrections were made in the Cro-
atian version of the questionnaire. The que-
stionnaire consists of two parts. In the frst
part, the examinees evaluate exposure to di-
rect aggressive behaviour (Have you had your
personal belongings taken?, Have you been
threatened or blackmailed?, Have you been
hit or beaten up?, Have other things happe-
ned to you?) and exposure to verbal-relatio-
nal aggression by other students (Have other
pupils called you nasty names?, Have other
pupils not wanted to hang around with you
Paediatrics Today 2012;8(2):114-126
119
Statistical analysis
The presence of psychosomatic diffculties at
the end of the school year and the number of
children participating in bullying behavior was
presented as absolute and relative frequencies.
The proportion of the appearance (odds ra-
tio) with a 95% confdence interval were cal-
culated for the needs of learning the role of
participation in peer violence as a risk factor
for particular types of psychosomatic diffcul-
ties, as well as for the evaluation of the role
of psychosomatic symptoms as a risk factor
for participation in peer violence. The data
processing was undertaken using the statisti-
cal program SPSS 17 for Windows (SPSS Inc.,
Chicago, IL, the USA). For evaluation of the
importance of the results, the importance le-
vel p<0.050 was used.
Results
There were 536 examinees in the frst resear-
ch. The questionnaires of 58 examinees were
incomplete and were not included in the sta-
tistical processing. The processing included
data from 478 examinees (89%).
There were 535 examinees in the second ro-
und of research. The processing only included
data of the 478 examinees whose data had been
processed in the frst round. There were 232
females (48.5%) and 246 males (51.5%). In the
frst round, 14% of the examinees were iden-
tifed as victims, 6.9% were identifed as bullies
and 18.8% were identifed as bully/victims.
In the second round of research 9.2%
of children were identifed as victims, 14.2%
were identifed as bullies and 29.7% were
identifed as bully/victims.
The frst aim of the research was to fnd
out if participation in bullying behavior at
the beginning of the school year (as victims,
bullies and bully/victims) would increase the
risk of development of psychosomatic diff-
culties at the end of the school year. All three
roles in the bullying behavior (victims, bulli-
they had experienced and the responses 2 or
3 (often or very often) in the part of the que-
stionnaire in which the examinees were asked
about their behaviour towards other children,
resulted in the categorization of the children
who were exposed to violent behaviour, but
who were also violent towards other children
or bully/victims. All the other examinees were
categorized as neutral. In the confrmative
factor analysis conducted on all 18 items par-
ticles of the School Relationship Questionnai-
re in order to check the factor structure of the
questionnaire with the analysis of basic com-
ponents with virimax rotation, four factors
were extracted Direct aggression directed
towards others, which explained 15.7% of
the total variance, the second factor Expo-
sure to direct aggressive behaviour explained
15.5% of the total variance, the third factor
Exposure to verbal/relational aggression
explained 14.5% of the total variance, and
the fourth factor Verbal/relational ag-
gression directed towards others explained
11.9% of the total variance. In our research,
the alpha coeffcients obtained for every su-
bscale showed the satisfactory reliability of
the type of internal consistency varying from
0.74 to 0.77. The alpha coeffcient for the
whole scale was =0.88.
The frequency of the health symptoms
was evaluated using a scale for self-evaluation
which we constructed for the needs of this
research, presenting the health symptoms
(problems with appetite, anxiety, dizziness,
feeling of fatigue without a clear reason, pain
(except headaches and abdominal pains), he-
adaches, nausea, vision problems, skin pro-
blems, abdominal pains, vomiting, sleeping
problems, and energy loss). For each of the-
se symptoms the examinees were asked to
evaluate its presence and frequency in the last
4 weeks on a scale from 1 to 3, depending on
the frequency of the presence of the symp-
toms (not at all/rarely = 1, often = 2, or
very often = 3).
D. Sesar and K. Sesar Bullying behavior and psychosomatic symptoms
120
Table 1 Incidence of psychosomatic symptoms during the school year among children who were not involved
in violent behaviour and children who were involved in violent behaviour (as victims, bullies and bully/victims )
at the beginning of the school year
Psychosomatic
symptoms
Involvement in violent
behaviour at the
beginning of the school
year (only children
without the specifc
psychosomatic symptom)
Incidence of
psychosomatic
symptoms at the
end of the school
year % (n/N)
Odds Ratio
(95% CI)
p
Problems with
appetite
No 23.6 (43/182) 1.34 (0.69-2.60) 0.385
Yes 29.3 (17/58)
Anxiety
No 19.0 (30/158) 2.59 (1.26-5.33) 0.010
Yes 37.8 (17/45)
Dizziness
No 7.4 (17/231) 1.65 (0.68-4.01) 0.268
Yes 11.6 (8/69)
Feeling of fatigue
without a clear reason
No 15.3 (33/215) 2.40 (1.26-4.56) 0.008
Yes 30.3 (20/66)
Pains (except headaches
and abdominal pains)
No 14.0 (31/221) 0.93 (0.40-2.13) 0.855
Yes 13.1 (8/61)
Headaches
No 31.0 (45/145) 1.03 (0.49-2.18) 0.935
Yes 31.7 (13/41)
Nausea
No 15.3 (31/202) 1.60 (0.77-3.29) 0.208
Yes 22.4 (13/58)
Vision problems
No 10.0 (24/241) 1.90 (0.91-3.94) 0.087
Yes 17.3 (13/75)
Skin problems
No 7.0 (17/242) 1.86 (0.82-4.26) 0.139
Yes 12.3 (10/81)
Abdominal pains
No 22.7 (34/150) 1.34 (0.64-2.84) 0.438
Yes 28.3 (13/46)
Vomiting
No 7.1 (14/196) 1.72 (0.66-4.47) 0.268
Certainly 11.7 (7/60)
Sleeping problems
No 9.6 (23/240) 1.92 (0.92-4.00) 0.083
Yes 16.9 (13/77)
Energy loss
No 9.9 (20/202) 2.18 (1.00-4.77) 0.050
Yes 19.4 (12/62)
es and bully/victims) were included together
and categorized as participation in bullying
behavior.
In order to avoid errors in drawing conclu-
sions about psychosomatic diffculties, children
with specifc psychosomatic diffculties at the
beginning of the school year were excluded from
processing. For example, in order to examine the
frequency of headaches after the period of victi-
mization, only those children categorized as "not
having" headaches at the beginning of the scho-
ol year were included in the processing. These
children were divided into two groups those
participating in bullying behavior and those not
participating in bullying behavior during the
year, and after that the incidence of headaches
during the year for both groups was examined.
Finally, the probability of development of speci-
fc psychosomatic diffculties during the school
year were calculated.
Table 1 showed the incidence of new
symptoms for the children participating
Paediatrics Today 2012;8(2):114-126
121
Table 2 Incidence of involvement in violent behaviour (as victims, bullies and bully/victims) during the
school year among children who were categorized as neutral and who had or who did not have specifc
psychosomatic symptoms at the beginning of the school year
Psychosomatic
symptoms
Presence of specifc
psychosomatic symptoms
at the beginning of the
school year (only children
who were not being invol-
ved in violent behaviour)
Incidence of invol-
vement in violent
behaviour at the end
of the school year
Odds Ratio
(95% CI)
p
Problems with appetite
No 41.1 (90/219) 0.94 (0.59-1.48) 0.775
Yes 39.5 (45/114)
Anxiety
No 36.5 (69/189) 1.47 (0.95-2.29) 0.087
Yes 45.8 (66/144)
Dizziness
No 37.6 (103/274) 1.97 (1.12-3.47) 0.019
Yes 54.2 (32/59)
Feeling of fatigue
without a clear reason
No 36.9 (93/252) 1.84 (1.11-3.05) 0.018
Yes 51.9 (42/81)
Pains (except headaches
and abdominal pains)
No 36.0 (95/264) 2.45 (1.43-4.21) 0.001
Yes 58.0 (40/69)
Headaches
No 38.1 (67/176) 1.24 (0.80-1.93) 0.331
Yes 43.3 (68/157)
Nausea
No 38.3 (92/240) 1.38 (0.85-2.24) 0.188
Yes 46.2 (43/93)
Vision problems
No 38.5 (112/291) 1.94 (1.01-3.71) 0.047
Yes 54.8 (23/42)
Skin problems
No 38.8 (111/286) 1.65 (0.87-3.06) 0.115
Yes 51.1 (24/47)
Abdominal pains
No 39.0 (71/182) 1.15 (0.74-1.78) 0.533
Yes 42.4 (64/151)
Vomiting
No 40.9 (97/237) 0.95 (0.58-1.53) 0.821
Yes 39.6 (38/96)
Sleeping problems
No 39.9 (114/286) 1.04 (0.46-2.37) 0.925
Yes 44.7 (21/47)
Energy loss
No 39.9 (97/243) 2.06 (1.02-4.16) 0.045
Yes 42.2 (38/90)
in bullying behavior as victims, bullies and
bully/victims, as well as those children not
participating in violent behaviour at the be-
ginning of the school year, but who in the
frst round did not have psychosomatic diff-
culties.
The results indicated that the children
participating in bullying behavior at the be-
ginning of the school year were more anxio-
us and tense (OR=2.59; p=0.010), were
more tired without a clear reason (OR=2.0;
p=0.008) and felt energy loss (OR=2.18;
p=0.050), i.e. they had an increased risk of
developing psychosomatic diffculties during
the school year, in comparison with children
not included in bullying behavior.
The second goal of the research was to
answer the question whether psychosomatic
diffculties at the beginning of the school
year were a risk factor for participation in
D. Sesar and K. Sesar Bullying behavior and psychosomatic symptoms
122
ved in bullying behavior during the school
year.
Discussion
Our results indicate that children who are in-
volved in peer violence at the beginning of the
school year showed an increased risk of deve-
loping new psychosomatic diffculties during
the school year. Equally, the children who had
particular psychosomatic diffculties at the be-
ginning of the school year showed an incre-
ased risk of to be involved in peer violence
during the school year.
According to the results of this research
children involved in bullying behavior had an
increased risk of developing psychosomatic
diffculties manifested as: anxiety, tension, fati-
gue without a clear reason and energy loss, in
comparison with the children who were not
involved in bullying behavior . Equally, partici-
pation in bullying behavior was not defned as
a risk factor for developing the other psycho-
somatic diffculties examined. Our research
results were the same as the results of prospec-
tive research conducted in the Netherlands by
Fekkes et al. (30), in which 1,118 children aged
from 9 to 11 were included.
This research found that the children
exposed to violent behaviour at the be-
ginning of the school year had an increased
risk of developing new psychosomatic diff-
culties, such as: bed wetting, abdominal pains
and tension. As well as our research, the rese-
arch conducted by Rigby (33) found a corre-
lation between participation in peer violence
and health problems such as: headaches, ab-
dominal pains, coughs, infammation of the
throat and so on. Some previous research re-
sults conducted among adolescents (34) con-
frmed the correlation between stressful life
events and psychosomatic diffculties.
Peer violence also has some specifc cha-
racteristics in relation to other forms of vio-
lent behaviour. It is categorized by repeated
bullying behavior during the school year. The
children participating in bullying behavior in
the frst round of the research (as victims,
bullies and bully/victims) were excluded
from this statistical analysis.
This procedure enabled examination
of the incidence of new children participa-
ting in bullying behavior during the school
year from among the children with specifc
psychosomatic diffculties on the frst ro-
und of the research and those without any
psychosomatic diffculties.
This statistical analysis also had the disad-
vantage of reducing the number of examinees
included in the statistical processing. Howe-
ver, if the children who, on the frst round
of the research were participating in bullying
behavior and who had specifc psychosomatic
diffculties had been included in the statistical
processing, it would have been more diffcult
to examine the correlation between participa-
tion in bullying behavior and psychosomatic
diffculties. If only the children participating
in bullying behavior or those with specifc
psychosomatic diffculties had been included
in the initial research, it would have been im-
possible to examine what happened frst, i.e., it
would have been impossible to defne if parti-
cipation in bullying behavior occurred before
the psychosomatic diffculties, or psychoso-
matic diffculties occurred before participati-
on in bullying behavior .
Table 2 shows the probability of partici-
pation in bullying behavior at the end of the
school year for children identifed as neutral
at the beginning of the school year. The chil-
dren identifed as neutral examinees at the
beginning of the school year had psychoso-
matic diffculties statistically more frequently,
manifested as dizziness (OR=1.97; p=0.019),
fatigue without a clear reason (OR=1.84;
p=0.018), pains (OR=2.45; p=0.001), vision
problems (OR=1.94; p=0.047) and energy
loss (OR=2.06; p=0.045) and they were
exposed to an increased risk of being invol-
Paediatrics Today 2012;8(2):114-126
123
sults, the research conducted by Nishin et al.
(37) did not fnd that physical increased the
risk for victimization.
A partial explanation of our research re-
sults was given by Olewus (3). He thought
that psychosomatic diffculties could infu-
ence the fact that the children became more
vulnerable and more exposed to violent be-
haviour, which made them easy victims for
aggressive children. Their less assertive beha-
viour could make them easier targets due to
the fact that there would be the least pro-
bability that they would fght for themselves.
However, it was possible that violent chil-
dren expected less resistance from children
with diffculties, which was the reason why
they were more inclined to choose such chil-
dren as their victims. According to the results
of research conducted by Cook et al. (38), in-
ternalized psychological diffculties were not
only the predictor for the fact that a child wo-
uld be exposed to violent behaviour, but they
were a predictor for involvement in bullying
behavior as a bullies and bully/victims. Howe-
ver, what should be emphasized is the fact that
according to its defnition, bullying behavior
happens in the social context and under the
infuence of the individual characteristics of
a child, as well as under the infuence of the
environment where it occurs. As a result, it is
important to become aware of the restricti-
ons of such results when examining only the
infuence of individual predictors of bullying
behavior, without examination of the envi-
ronmental characteristics of the child, as well
as the characteristics of the environment in
which it occurs. Future research should also
include the environment, for a better under-
standing of the conditions under which peer
group violence occurs (39).
The restrictions of the study
Therefore, it is important to indicate the
methodological restrictions of the research
actions, sometimes over several years, which
means continuous exposure to stressful
events (35). According to some authors (33),
which is also confrmed by this research re-
sults, it seems that an increase in the stress
level as a result of involvement in bullying
behavior mediates between involvement in
peer violence and the health problems.
The second explanation for these resear-
ch results are the results conducted by Va-
illancourt et al. (36), who found that stress
as the result of peer violence reduces the
immunological functions of the organism,
i.e. the cortisone mediates between the peer
violence and the physical health.
If involvement in bullying behavior itse-
lf is not the cause of the psychosomatic
diffculties, it should be examined whether a
child having these psychosomatic diffculties
has been a participant in bullying behavior
in some way. An additional source of stre-
ss such as involvement in bullying behavi-
or which a child has to deal with defnitely
will not help a child trying to deal with the
psychosomatic diffculties.
The children who wasn't involved in peer
violence at the begging of the school years
and who had psychosomatic diffculties ma-
nifested as: dizziness, fatigue without a clear
reason, pains, vision problems and energy
loss at the beginning of the school year, had
increased risk to be involved in peer violence
during the school year. The other psychoso-
matic symptoms were not indicated as risk
factors for involvement in bullying behavior.
It was found that problems with appetite at
the beginning of the school year were a risk
factor for involvement in bullying behavior
during the school year, which was confr-
med in the research conducted by Fekkes et
al. (30). Despite the fact that in that research
some other psychosomatic symptoms were
examined such as: headaches, abdominal pa-
ins and night urination, they were not iden-
tifed as risk factors. Unlike our research re-
D. Sesar and K. Sesar Bullying behavior and psychosomatic symptoms
124
conducted, which could infuence the re-
sults. The evaluation of bullying behavior
and other variables in the research was un-
dertaken by means of questionnaires which
is a frequent and valid research method (40).
However, the evaluation of the children par-
ticipating in bullying behavior by means of
a questionnaire for self-evaluation could be
a diffculty, especially for identifcation of
those children who are frequently violent
towards other children, but not aware of the-
ir negative behaviour towards other children,
and they may refuse to admit their active role
in bullying behavior. Some authors (2, 41, 42)
also suggested that indirect aggression could
be underestimated by self-evaluation due to
the fact that it is often undefned by the ag-
gressors and in some cases it may be uncons-
cious. In order to minimalize subjectivity, the
examinees were given defnitions of bullying
behavior with examples of violent beha-
viour. Future research should include other
measures of the peer group evaluation which
would contribute to its objectivity, such as:
an interview, monitoring children in their
natural conditions, as well as examination of
other children and the adults, not only in the
school environment, but also in the family
environment and the neighbourhood (43).
Equally, the fact is that depressive chil-
dren have a tendency to experience things
in a more negative way and they often have
health problems or negative experiences (41).
The data processing related to evaluation of
the risk for developing psychosomatic diff-
culties in the time between the two rounds of
research, and only those children who reco-
gnized themselves as participants in bullying
behavior were included initially, which meant
that some children were excluded from the
processing due to that fact. The research was
conducted in the area of four schools in one
municipality, therefore it cannot be said that
it is an epidemiological sample, which re-
stricts us from generalization of the results.
Conclusions
This research indicates that participation in
bullying behavior increases the probability of
developing psychosomatic diffculties in chil-
dren involved in the bullying behavior. Equally,
the presence of the psychosomatic diffculties
in children who are not involved in bullying be-
havior increases the risk for those children to
become participants of the bullying behavior.
The research results are especially important
for paediatricians and other health workers
who should be aware of the role of involve-
ment in bullying behavior in the etiology of
these psychosomatic diffculties.
Authors contributions: Conception and desi-
gn: DS, KS; Acquisition, analysis and interpre-
tation of data: DS, KS; Drafting the article: KS;
Revising it critically for important intellectual
content: DS, KS.
Confict of interest: The authors declare that
they have no confict of interest. This study was
not sponsored by any external organisation.
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Citation: Sesar D, Sesar K. Psychosomatic problems as the results of participation in bullying behaviour
or risk factor for involvement in bullying behavior. Paediatrics Today. 2012;8(2):114-126.
Paediatrics Today 2012;8(2):114-126
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